RHIA Exam 309 Questions with Verified Answers
A discharge summary must be completed within____days after discharge for most patients but within
... [Show More] ___for patients transferred to other facilities. Discharge summaries are not always required for patients who were hospitalized for less than ___ - CORRECT ANSWER 30 days/24 hours/48 hours
systematic random sample - CORRECT ANSWER a simple random sample that may be generated by selecting every fifth or every tenth member of the sampling frame. In order to ensure that a systematic random sample is truly random, the sample frame should not be sorted in an order that might bias the sample. Example: If an analyst is studying the wait times at a clinic and the only list of patients available is on hard copy, which sampling technique is the easiest to use. Systematic sampling
Entity relationship modeling - CORRECT ANSWER is a type of conceptual modeling. Conceptual models are abstract and encourage high-level problem structing; they help establish a common ground for communication between users and developers. The entity-relationship diagram was developed to depict relational database structures.
The emergency health record should include - CORRECT ANSWER time and means of arrival, treatment rendered, and instruction at discharge. Facilities are required to do a pertinent history, including the chief complaint and onset of illness or injury but not a complete medical history of the patient
Minimum Data set - CORRECT ANSWER a component of the resident assessment instrument (RAI) and is used to collect information about the resident's risk factors and to plan the ongoing care and treatment of the resident in the long-term care facility.
many-to-many relationship - CORRECT ANSWER occurs only in a data model developed at the conceptual level. In this case, the relationship between patients and consulting physicians is a many-to-many. For each instance of patient, there could be many instances of consulting physician because patients can be seen by more than one consulting physicians. For each instance of consulting physician, there could be many patients because the physician sees many patients.
metadata - CORRECT ANSWER data about data. metadata are structured information used to increase the effective use of data. One of the most familiar types of metadata is used to describe data in databases. Data element name, data type, and field length are examples of this kind of metadata.
Health Record Matrix - CORRECT ANSWER Identifies and tracks the physical location of each paper document and the source of each electronic document that constitutes the LHR. The documentation of the LHR may physically exist in separate and multiple paper-based or electronic systems. This complicates the process of pulling the entire legal record together in response to authorized requests to produce the complete patient record.
The legal health record for disclosure consists of: - CORRECT ANSWER the data, documents, reports and information that comprise the formal business records of any healthcare entity that are to be utilized during legal proceedings. Understanding legal health records requires knowledge of not only what comprises business records used as legal health records, but also the processes as well as the physical and electronic systems used to manage these records.
privileged communication - CORRECT ANSWER information held confidential within a protected relationship as delineated by state law. Example: Mary goes to her doctor to discuss her current medical conditions.
Firewall - CORRECT ANSWER a part of a computer system or network that is designed to block unauthorized access while permitting outward communication.
A firewall can limit internal users from accessing various portions of the internet
The most common place to find a firewall is between the healthcare entity's internal network and the internet
It supports access control policy between two networks.
It cannot prevent all types of attacks
How long does the privacy rule use for the period of time which privacy rule-related documents must be retained? - CORRECT ANSWER Six years. The six-year time frame refers to the date the document was created or the last effective date of the document. Such documents include policies and procedures, the notice of privacy practices, complaint dispositions, and other actions, activites, and designations that must be documented per privacy rule requirements.
corporate negligence - CORRECT ANSWER a legal doctrine that was established by a judicial decision handed down in the 1965 court case Darling v Charleston Community hospital. The court in this case ruled specifically that hospital governing boards have a duty to institue a means to evaluate and council medical staff who personally perform services on a patient that results in harm due to unreasonable risk. Hospitals may be held liable when a member of the medical staff fails to meet established standards of patient care.
the privacy rule requires covered entities to - CORRECT ANSWER arrange a convenient time and place for the individual to inspect his or her record. However, the covered entity also has an obligation to protect the records integrity. Therefore, it is within the covered entitiys right to provide an authorized HIM staff member to be present when the individual reviews the record.
fundraising activities - CORRECT ANSWER Those that benefit the CE, the covered entity may use or disclose to a BA or an institutionally related foundation without authorization, demographic information and dates of healthcare provided to the individual.
Must have an option to Opt Out from receiving the material.
If a fundraising activity targets individuals based on their diagnosis, prior authorization is required
The privacy rule - CORRECT ANSWER establishes a patients right to receive an accounting of disclosures of their PHI made by a covered entity.
first step in conducting the security risk analysis - CORRECT ANSWER consider their own characteristics and environment and implement reasonable and appropriate measures to protect against reasonably anticipated threats and hazards to the security of PHI. The security risk analysis process provides covered entities and business associates with the structural framework up on which to bulid their securty plan
Addressable Implementation Specifications - CORRECT ANSWER Addressable specifications allow a covered entity flexibility when:
(1) it is determined that the specification is not reasonable or appropriate for the covered entity's environment
(2) the covered entity documents why the specification is not reasonable or appropriate and implements an equivalent alternative measure as appropriate.
(3) Implementing "security measures to reduce risks and vulnerabilities to a reasonable and appropriate level" is a required specification, while encryption of electronic PHI is an addressable specification
The breach notification rule requires - CORRECT ANSWER covered entities and business associates to establish policies and procedures to investigate an authorized use or disclosure of PHI to determine if a breach occured to
Record locator service (RLS) - CORRECT ANSWER A process that seeks information about where a patient, once identified, may have a health record available to the HIO. It manages the pointers to the information on the servers of the HIE participants. The pointers in a RLS can include a person identification number and metadata. The RLS does NOT provide information about the record, it merely points to where it might be found. Data are not stored in a centralized database and records are only provided when queried.
Qualitative standards - CORRECT ANSWER specify the level of service from a function such as accuracy rate, error rate, turnaround time and response time. In this case, timely response to release of information requests can indirectly impact patient care. To properly communicate performance standards, managers need to make the distinction between quantitative and qualitative standards and identify examples of each for the health information systems functions.
A possible justification for building an information system in-house rather than purchasing one from a vendor - CORRECT ANSWER the facility has development teams that they do not want to give up
gross death rate - CORRECT ANSWER the proportion of all hospital discharges that ended in death. It is the basic indicator of mortality in a healthcare facility. It is calculated by dividing the total number of deaths occurring in a given time period by the total number of discharges, including deaths, for the same time period. 25/500=0.05x100=5%
work distribution chart - CORRECT ANSWER A matrix that depicts the work being done in a particular workgroup in terms of specific tasks and activities, time spent on tasks, and the employees performing the tasks
is initially completed by each employee and includes all responsible task content. Can help when problems have been identified with work proceses such as too much time spent on unimportant tasks.
pie chart - CORRECT ANSWER a chart that shows the relationship of a part to a whole.
pie charts can be used to show the component parts of a single group or variable.
incidence rate - CORRECT ANSWER a computation that compares the number of new cases of a specific disease for a given time period to the population at risk for the disease during the same period.
a hospital is looking to cut cost on a vendors proposal for health IT should consider - CORRECT ANSWER acquiring it's own hardware
Boolean Search - CORRECT ANSWER A Boolean operator is a computer-programming term for conjunctions like, AND, OR, and NOT which can be used to construct more complex search conditions. Usually found under the advanced options.
Structured Query Language (SQL) - CORRECT ANSWER A language used to create and manipulate databases.
Truncation - CORRECT ANSWER In metric verse, the omission of an unaccented syllable at either end of a line
Wildcard search - CORRECT ANSWER search that uses characters such as * or ? to replace letters in a search term
Monitoring Results - CORRECT ANSWER enables a hospital to understand if the present system is currently supporting the needs of the organization and whether the next step, identify needs will set in motion new or further development or acquisition of health IT
Discrete Data (Quantitative) - CORRECT ANSWER Numerical data values that can be COUNTED. whole numbers that may or may not be related. A bar graph is the best data display tool to use
Application Service Provider (ASP) - CORRECT ANSWER A company that provides the software, support, and computer hardware on which to run the software from the user's facilities over a network.
There is much less upfront captial outlay and fewer IT staff required in house. The ASP acquisition strategy may be considered essentially a financing model
Case Mix Index - CORRECT ANSWER The average relative weight of all cases treated at a given facility or by a given physician, which reflects the resource intensity or clinical severity of a specific group in relation to the other groups in the classification system
The weight of each ms-drg is multiplied by the number of discharges for that ms-drg. Total weights are summed and divided by the number of toal discharges to arrive at the case-mix index
Data provenance - CORRECT ANSWER Record of where data originated and have moved
refers to the ablitiy to track the source of data
super users - CORRECT ANSWER individuals with normal jobs who happen to be skilled at learning new information technology and can help others master new technology; they are not intended to replace scribes, trainers, or technicians
Pareto Chart - CORRECT ANSWER a bar graph whose bars are drawn in decreasing order of frequency or relative frequency
a type of bar graph that uses data to determine priorities in problem solving.
Best way to ensure that elements of a HIS work together is to - CORRECT ANSWER ensure standards are applied to software development that support interoperability
Haldol - CORRECT ANSWER Haloperidol (antipsychotic) used for behavior or mental conditions
division - CORRECT ANSWER Cutting into a body part without draining fluids and/or gases from the body part in order to separate or transect a body part
Clustering - CORRECT ANSWER the practice of coding or charging one or two middle levels of service codes exclusively under the philosophy that, although some will be higher and some lower, the charges will average out over an extended period.
Capitated rate - CORRECT ANSWER a method of payment for health services in which the third-party payer reimburses providers a fixed, per capita amount for a period. Per capita means per head or per person. A common phrase in capitated contracts is per member per month. The PMPM is the amount of money paid each month for each individual enrolled in the health insurance plan. Capitation is characteristic of HMOs.
Workers Compensation - CORRECT ANSWER is a payer that pays for healthcare services due to work-related incidents. Because workers compensation is paying the bill, they are the third-party.
Allowing patterns of retrospective documentation, hiding or ignoring negative quality review outcomes, and hiding incomplete health records from accreditation surveyors are unethical behaviors for which of the following Code of Ethics principle?
A. Advocate and uphold the right to privacy
B. Put service before self-interest
C. Represent the profession accurately to the public
D. Respect the inherent dignity and worth of every person - CORRECT ANSWER put service before self-interest
What is the payment reduction for facilities that fail to successfully meet the requirements of medicare's quality reporting programs - CORRECT ANSWER 2 percent reduction
Integrated Delivery System (IDS) - CORRECT ANSWER A network of organizations that provides or arranges to provide a coordinated continuum of services to a defined population and is willing to be held clinically and fiscally accountable for the outcomes and health status of the population serviced.
collaboration integration of healthcare providers. The goal of the IDS isa seamless delivery of care along the continuum of care, so one bill would be generated. (even if the care provided is over a 10 month period)
Value-based care - CORRECT ANSWER includes 4 domains: safety, clinical care, efficiency and cost reduction, and person and community engagement. Each domain has measures that must be reported to CMS
HCAHPS - CORRECT ANSWER Hospital Consumer Assessment of Healthcare Providers and Systems
part of the person/community engagement domain
strategy - CORRECT ANSWER a plan of action or policy designed to achieve a major or overall aim.
characteristics of strategy: an action or set of actions, a description of how one intends to achieve the goals, a plan to improve the organizations fit within the external environment
implementation plan is critical to the successful execution, it is not a characteristic of strategy.
tracer methodology - CORRECT ANSWER A process the Joint Commission surveyors use during the on-site survey to analyze an organization's systems, with particular attention to identified priority focus areas, by following individual patients through the organization's healthcare process in the sequence experienced by the patients; an evaluation that follows (traces) the hospital experiences of specific patients to assess the quality of patient care; part of the new Joint Commission survey processes (LaTour 953-954)
Profitability Index - CORRECT ANSWER Net Present Value / Investment Required
divide the present value of the cash inflows by the present value of the cash outflows.
data steward - CORRECT ANSWER An individual responsible for the management of critical data elements, including identifying and acquiring new data sources; creating and maintaining consistent reference data and master data definitions; and analyzing data for quality and reconciling data issues.
are embedded within an organizations business unit and responsible for monitoring the data quality of the unit
Accession number - CORRECT ANSWER A number assigned to each case as it is entered in a cancer registry
consists of the first digits of the year the patient was first seen in the facility, with the remaining digits assigned sequentially throughout the year.
Healthcare Effectiveness Data and Information Set (HEDIS) - CORRECT ANSWER a set of standard performance measures designed to provide purchasers and consumers of healthcare with the information they need to for comparing the performance of managed healthcare plans.
breach notification laws - CORRECT ANSWER do not exist in numerous states, but they often are not tailored to medical information
Context-based access control (CBAC) - CORRECT ANSWER The most stringent type of access control, which takes into account the person attempting to access the data, the type of data being accessed, and the context of the transaction in which the access attempt is made.
Omnibus Rule - CORRECT ANSWER Set of regulations enhancing patients' privacy protections and rights to information and the government's ability to enforce HIPAA
created a new fine structure for civil monetary penalities based on a four tier system for HIPAA violations. Tiers 3 and 4 are based on violations that have been determined to be due to willful neglect. If a breach is corrected within 30 days from the date of discovery it would fall into Tier 3. If it wasn't corrected it would be a tier 4.
a patient requests that disclosures made from her medical record be limited to specific clinical notes and reports. Given HIPAA requirements, how must the hospital respond - CORRECT ANSWER common practice for covered entities is to accept the request, but not to agree to the restriction because of legal implications to the covered entity should the restriction be violated
the privacy rule lists two circumstances where phi can be used or disclosed without the individuals authorization - CORRECT ANSWER 1.disclosing PHI to a family member or close friend that is directly relevant to his or her involvement with the patients care or payment.
Facility access controls - CORRECT ANSWER A visitor walks through the computer department and picks up a CD from an employee's desk. What security controls should have been implemented to prevent this security breach?
technical safeguards - CORRECT ANSWER identification and authorization, encryption, firewalls, malware protection, application design
includes automatic log-off, which ensures electronic processes that terminate an electronic session after a predetermined time of inactiviy
Covered entities are responsible for their workforce, which consists not only of employees, but also volunteers, student interns and trainees. Workforce members are not limited to those who receive wages from the CE - CORRECT ANSWER a volunteer is a workforce member in relation to the hospital
employees are not covered by - CORRECT ANSWER privacy rule
the privacy rule permits individuals to request that a covered entity amend a PHI record about the individual in a designated record set unless - CORRECT ANSWER the report was erroneously placed in the record. It is not part of the designated record set.
One of the medical staff committees at st vincent hospital is responsible for reviewing cases of patients readmitted within 14 days after discharge. This review of patients' medical records is considered healthcare - CORRECT ANSWER operations
there is the least amount of interoperability between - CORRECT ANSWER EHR in a physician office and revenue cycle management
MPI: Master Patient Index manager - CORRECT ANSWER is responsible for ensuring that registration interfaces are properly built and tested
line/plot graph - CORRECT ANSWER displays trends over time
Normal Bell Curve - CORRECT ANSWER the normal distribution is actually a theoretical family of distributions that may have any mean or any standard deviation. It is bell shaped and symmetrical about the mean. because it is symmetrical, 50% of the observations fall above the mean and 50% fall below it. In a normal distribution, the mean, median and mode are equal.
Histogram - CORRECT ANSWER A graph of vertical bars representing the frequency distribution of a set of data. (nominal or ordinal data)
Levels of interoperability - CORRECT ANSWER basic--functional--semantic
basic relates to the ability to successfully transmit and receive data from one computer to another
functional refers to sending messages between computers with a shared understanding of the structure and format of the message.
The use of clinical terminologies in EHRs to provide standardized data is essential to achieving semantic interoperability.
the ICU bed count in the state has relaized a decrease of 20% bed count is a component needed to calculate occupancy rates for any facility. - CORRECT ANSWER reduction of ICU beds at any healthcare facility in the state has the potential to increase the volume of patients in this hospitals ICU
Federated inconsistent databases - CORRECT ANSWER Model for HIE includes multiple enterprises agreeing to connect and share specific info in a point to point manner
information warehouse - CORRECT ANSWER Allows organizations to store reports, presentations, profiles, and graphics interpreted and developed from stores of data for reuse in subsequent organizational activities.
the master patient index - CORRECT ANSWER Permanent database including every patient ever admitted to or treated by the facility. the MPI must be kept permanently
it is the key to an effective retention and retrieval system of health records in a facility.
results management application - CORRECT ANSWER enables results of a diagnostic study to be compared and displayed with other data.
character and symbol recognition technologies - CORRECT ANSWER include bar coding, optical character recognitions and gesture recognition technologies.
clinician web portal - CORRECT ANSWER used by physiciaans to access multiple sources of patient information within the healthcare organizations network.
predictive modeling - CORRECT ANSWER applies statistical techniques to determine the likelihood of certain events occurring together. Statistical methods are applied to historical data to learn the patterns in the data. These patterns are used to create models of what is most likely to occur.
contingency table - CORRECT ANSWER displays the relationship between two categorical variables. They are often referred to by the number of rows and columns.
Discharged Not Final Billed (DNFB) - - CORRECT ANSWER A report that includes all patients who have been discharged from the facility but for whom, for one reason or another, the billing process is not complete.
a bill cannot be generated until the coding is complete, so organizations routinely monitor the DNFB days.
Hospital Compare - CORRECT ANSWER A website created by CMS and the Hospital Quality Alliance to promote reporting on hospital quality of care.
Reports on 139 measures of hospital quality of care for heart attack, heart failure, pneumonia and the prevention of surgical infections. The data available on Hospital Compare is reported by hospitals to meet the requirements of the medicare value based purchasing program.
how do providers benefit from the health insurance exchanges created under the ACA - CORRECT ANSWER Providers should see an increase in reimbursement both from newly insured patients and from patients who are now eligible for medicaid under the expanded programs
Aging of accounts standard incrememnt - CORRECT ANSWER 30 days
what benefit of comparing the coding assigned by coders to the coding that appears on the claim - CORRECT ANSWER may find claim generation issues that cannot be found in other ways
Medicare participating physicians - CORRECT ANSWER payments are 80% of medicare fee schedule. noPAR payments are 95% of the 80%.
Focused reviews on lower weighted MS-DRGs from triples and pairs - CORRECT ANSWER indicats areas of risk related to lower weighted MS-DRGs from triple and pair combinations which may be the result of a coder missing secondary diagnosis. A focused audit based on this specific potential problem area could help to identify these cases. Optimization seeks the most accurate documentation, coded data, and resulting payment in the amount the provider is rightly and legally entitled to receive
Dr. Smith, a surgeon at Community Hospital, is trying to understand how she can help the hospital improve reimbursement from Medicare. The HIM manager explains to Dr. Smith that reducing catheter-associated UTIs and surgical site infections would improve the hospital's scores in which of the following domains of the Medicare Value-Based Purchasing program? - CORRECT ANSWER safety
Most facilities begin counting days in accounts receivable at which of the following times? - CORRECT ANSWER date the claim drops
three competencies common to all successful change - CORRECT ANSWER Leadership, change management and strategic development
state licensure agencies - CORRECT ANSWER What type of organization works under contract with the CMS to conduct Medicare/Medicaid certification surveys for hospitals?
Three ways to address conflict - CORRECT ANSWER compromise, control and constructive confrontation
constructive confrontation - CORRECT ANSWER a method of conflict resolution in which both parties meet with an objective third party to explore their perceptions and feelings. The desired outcome is to produce a mutual understanding of the issues and to create a win-win situation
Hay Guide Chart-profile Method (Hay plan) - CORRECT ANSWER Refined version of the point method used by approx. 8000 public and private sector organizations worldwide to evaluate clerical, trade, technical, professional, managerial, and/or executive-level jobs.
used as a job evalutaion tool
Contract Elements - CORRECT ANSWER agreement, offer, acceptance, consideration
DURSA - CORRECT ANSWER data use and reciprocal support agreement, legal binding contract that draws from federal and local laws and defines requirements for participation in eHealth exchange national network, agreement also addresses sanctions for violations of contract
Net Income Equation - CORRECT ANSWER Net Income = Revenues - Expenses
Net assets - CORRECT ANSWER Non current assets + net current assets - long term liabilities
work sampling technique - CORRECT ANSWER a statistical method that reviews a select portion of tasks performed and provides baseline data for further job performance assessment.
work distribution chart - CORRECT ANSWER is initially completed by each employee and includes all responsible task content. (LaTour 801)
the him manager tasked the coding manager to development a dashboard that shows the discharges pending final billing so that she can plan staffing. Because this data changes throughout the day, what analysis technique is needed. - CORRECT ANSWER real time analysis
a physician on your staff asked you to help her collect information about the effects of smoking during pregnancy on the birth weight of the babies. You were asked to collect the following information: whether or not the mothers smoke during pregnancy, birth weight of the babies, apgar scores at one minute and apgar scores at 5 minutes. The scales of these variables would be: - CORRECT ANSWER nominal (yes or no question), ordinal (apgar--because the order of the numbers is meaningful), interval, ratio (birth weight--scaled data--unit of measure)
a pattern used in computer based patient records to capture data in a structured manner is a called a
_______. One benefit of using a ______ is to ensure data integrity upon data entry. - CORRECT ANSWER template
____ is a statistic that is used to describe the association or relationship between 2 variables. - CORRECT ANSWER correlation
quantitative analysis - CORRECT ANSWER is conducted to determine whether documentation is complete and accounted for in the medical record. If information is missing or incomplete, it is flagged for the provider to review and complete. It is generally conducted retrospectively.
when an entity relational diagram is implemented as a relational database, the entity will become a ____ - CORRECT ANSWER table. It becomes a table because it is the person, place or thing about which you are collecting the data in your database.
alternative hypothesis - CORRECT ANSWER the compliment of the null hypothesis and typically requires some action to be taken. In this scenario, the analyst is comparing emergency department wait times between weekends and weekdays. The alternative hypothesis would be that the average wait time is longer on weekends.
Metadata - CORRECT ANSWER data contained in the data dictionary. Metadata are descriptive data that characterize other data to create a clearer understanding of their meaning and to achieve greater reliability and quality of information.
source systems - CORRECT ANSWER Systems that provide a source of organizational data.
information systems that capture and feed data into the EHR. Source systems include the electronic medication administration record, laboratory information system radiology information systems, hospital information system, nursing information systems, and more.
biomedical research - CORRECT ANSWER basic and applied research aimed at increasing medical knowledge and understanding
is considered the ancillary function of the health record.
Uniform Hospital Discharge Data Set (UHDDS) - CORRECT ANSWER Used for reporting inpatient data in acute care, short-term care, and long-term care hospitals.
Minimum set of items based on standard definitions to provide consistent data for multiple users.
Required for reporting Medicare and Medicaid patients.
name of element, definition, application in which the data element is found, locater key, ownership, entity relationships, date first entered system, date terminated from system and system of orgin - CORRECT ANSWER examples of metadata
scatter diagram - CORRECT ANSWER A correlation chart that uses a regression line to explain or to predict how the change in an independent variable will change a dependent variable.
whenever a scatter diagram indicates that the points are moving together in one direction or another, conclusions about the variables relationship, either positive or negative become evident.
a data analysis tool used to plot points of two variable suspected of being related to each other in some way.
Resident Assessment Instrument (RAI) - CORRECT ANSWER a federally mandated standard assessment used to collect demographic and clinical data on residents in a Medicare- or Medicaid-certified long-term care facility. It consists of three components: the Minimum Data Set (MDS) Version 3.0, the Care Area Assessment (CAA) process, and the RAI utilization guidelines (LaTour 199)
How do healthcare providers use the administrative data they collect? - CORRECT ANSWER for regulatory, operational and financial purposes
what is the most secure signature type - CORRECT ANSWER the digital signature is similar to the electronic signature except that is uses encryption to provide nonrepudiation to prove the authenticators identity,
who is responsible for the quality of documentation of the record - CORRECT ANSWER The provider
identify the level in the data model that describes how the data is being stored in the database - CORRECT ANSWER physical data model. The users are not involved with this level of the database because of its technical complexity
Entity Relationship Diagram (ERD) - CORRECT ANSWER A diagram that depicts an entity relationship model's entities, attributes, and relations.
describes how the tables work together. The diagram is a graphic representation of the entities, attributes and relationships that are part of a database and is a data modeling tool.
Disaster Recovery Plan (DRP) - CORRECT ANSWER a plan to restore an organization's IT capability in the event that its data center is destroyed
The technological aspect of business continuity planning. HIM professionals assist in designing disaster recovery plans that address documenting information in the health record during down time or a disaster.
Skewness - CORRECT ANSWER A measure of the shape of a data distribution. Data skewed to the left result in negative skewness; a symmetric data distribution results in zero skewness; and data skewed to the right result in positive skewness.
If the longer tail is on the right, the curve is skewed to the right. If the longer tail is on the left, the curve is skewed to the left.
Hybrid health records - CORRECT ANSWER mixture of paper and electronic, or multiple electronic systems that do not communicate or are not logically architected for record management.
these records are increasingly seen as the most common transition points between fully paper and completely electronic records
Uniform discharge data set (UDDS) - CORRECT ANSWER adopted in 1974 by the federal government as the standard for collecting data for the medicare and medicaid programs. When the prospective payment act was enacted in 1983, UHDDS definitions were incorporated into the rules and regulations for implementing drgs. A key component was the incorporation of the definitions of principal dx, principal procedure and other significant procedures, into the DRG algorithm.
minimum data set for long term care - CORRECT ANSWER is part of the U.S. federally mandated process for clinical assessment of all residents in Medicare or Medicaid certified nursing homes. This process provides a comprehensive assessment of each resident's functional capabilities and helps nursing home staff identify health problems.
an assessment form used to collect demographic and clinical data on nursing home residents. it consists of a core set of screening and assessment elements based on common definitions. To meet federal requirements, long-terms facilites must complete an MDS for every resident at the time of admission and at designated reassessment points throughout the residents stay.
physician index - CORRECT ANSWER categorizes patients by primary physician. It guides the retrieval of cases treated by a particular physician. This index is created simply by sorting patients by physician [Show Less]